Sunil Kumar, Bhavna Saxena, Neera Gupta Kumar, Rakesh Kumar

Radiology departments play host to a wide variety of patients for both diagnostic and therapeutic procedures. These may range from otherwise healthy trauma victims with serious injuries undergoing diagnostic procedures to patients with preexisting comorbidities undergoing therapeutic interventional procedures. A high-risk situation seen within radiology suites is the occurrence of contrast media-induced reactions with varying degrees of severity, which may be serious enough to progress to cardiac arrest. Regardless of the severity, such situations demand immediate action and prompt treatment to prevent poor and potentially catastrophic outcomes for the patient, the highest chance of survival being possible only if cardiopulmonary resuscitation (CPR) is begun within 2 minutes of cardiac arrest by well-trained healthcare provider (HCP). It is therefore essential that all clinical staff posted in radiology have basic resuscitation skills which are regularly updated.

The recommendations of the ILCOR (International Liaison Committee on Resuscitation) are the basis of the guidelines recommended by most international resuscitation organizations such as the European Resuscitation Council (ERC), the American Heart Association (AHA), the Australian and New Zealand Committee on Resuscitation (ANZCOR), the Heart and Stroke Foundation of Canada (HSFC), etc. The recommendations adopted by the AHA are commonly accepted and followed worldwide and will be the basis of the recommendations in this chapter.

The following is an example of a patient brought to the radiology suite and the possible scenarios, which we may encounter within the context of adverse reactions of varying degrees of severity right up to the life-threatening ones.

A 62-year-old male with history of carcinoma pancreas is brought to the radiology suite for a contrast-enhanced CT scan of the abdomen. He is given IV contrast.

Scenario 0 is the commonest and is probably the reason that when any of the other scenarios occur, there is discomfort to chaos in the radiology suite! The detailed management of these adverse events (Scenarios 1–2) is mentioned elsewhere in this book.

In this chapter, we will be using a systematic approach to these events, an approach that is simple and protocol-based. Using a universal, protocol-based approach or a common language of assessment and management helps in minimizing errors and decreases the likelihood of missing out critical steps, thereby leading to a better outcome.

The systematic approach

The systematic approach to an adverse event as suggested by the American Heart Association (AHA) requires the HCP to first determine the level of consciousness of the patient after ensuring scene safety (Fig. 1.17.1). Prior to approaching any patient, scene safety must be ensured, both for the HCP and for the patient. This means safety measures taken to prevent transmission of diseases, based on the assumption that all body fluids of a patient which the HCP may come in contact with, might be infectious. These universal precautions include the use of some or all of the personal protective equipment (PPE) such as gloves, masks, gowns or specialized clothing, face shields, and protective eyewear, depending upon the need. In the context of the radiology work environment, it also includes ensuring safety regulations such as strict zone restrictions for the use of ferromagnetic objects in magnetic resonance suites.

Once the level of consciousness is ascertained, the HCP calls for reinforcements and the emergency cart or code cart as he prepares for further management, which depends upon whether the patient is responsive or unresponsive.

If the patient is conscious and responsive (scenarios 1 and 2), the systematic approach prompts the HCP to conduct the primary and secondary assessment and management. If, on the other hand, the patient is unresponsive (scenario 3), the HCP immediately begins the BLS assessment and management first, followed by primary and secondary assessment and management. At any time during primary and secondary assessment and management, if a responsive patient becomes unresponsive, BLS assessment and management is immediately initiated (Fig. 1.17.1).

Before we discuss the application of these approaches in context of adverse events in radiology, let us review these approaches.

Patient conscious and responsive

If the patient is conscious and responsive (scenarios 1 and 2), the systematic approach prompts the HCP to ask for reinforcements along with emergency cart and then conduct a series of assessment and management steps called the primary and secondary assessment and management. These can be conducted one after the other or simultaneously, depending upon the availability of HCPs. The reinforcements summoned for a responsive patient who has had an adverse event are called rapid response team (RRT) in many centres.

The primary assessment and management employs the ABCDE approach, i.e., assessment and management of Airway, Breathing, Circulation, Disability and Exposure. It is carried out by assessing each component and taking action simultaneously by different members of the team of HCPs.

The secondary assessment and management involves finding out the underlying cause(s) for the adverse condition so as to address reversible factors as early as possible. The underlying condition is looked for by structured history taking and exploring the most common known causes for adverse condition.

Details of primary and secondary assessment and management

The components of ABCDE approach for primary assessment and management are Airway, Breathing, Circulation, Disability and Exposure. The details of these components are described as follows:

Airway:

• • Assessment: The HCP assesses the patency of the airway. If the patency is doubtful, the airway is made patent by using airway opening manoeuvres and/or adjuncts, or medication, depending upon the requirement of the case.
  
• • Management: Manual airway opening manoeuvres are head-tilt chin-lift and jaw thrust. If these are not sufficient, then suctioning, airway adjuncts such as oropharyngeal airway (OPA), nasopharyngeal airway (NPA) or advanced airway devices may be used. Advanced airway devices include the supraglottic airway devices (SADs) (e.g., laryngeal mask airway, etc.) or endotracheal intubation (ETT). Medication may be needed in case of obstruction due to spasm/bronchoconstriction.

If bag-mask ventilation is adequate, then it is recommended to continue with the same. SADs and ETT have to be used when bag-mask (with or without adjuncts) is not enough to keep the airway patent. Endotracheal intubation is done if there is return of spontaneous circulation and the patient remains unconscious or needs respiratory support. However, there are some exceptions to this rule. Early intubation is recommended if airway obstruction is due to anaphylaxis or inhalational burn injuries. Placement of an advanced airway requires confirmation of its correct placement, which is done by physical examination and quantitative waveform capnography (end-tidal CO₂). Subsequently, the airway device must be properly secured and monitored to prevent dislodgement.

Breathing:

• • Assessment: The adequacy of ventilation and oxygenation is assessed. Ventilation is assessed by quantitative waveform capnography (if available) and clinical criteria such as bilaterally equal chest wall movement. Oxygenation is assessed by pulse oximetry.
  
• • Management: Provide supplementary oxygen whenever required. For patients in cardiac arrest, 100% oxygen should be given. In other cases, oxygen should be titrated to achieve a saturation of 94% or more. Excessive ventilation should be avoided

Circulation:

• • Assessment: The following are assessed:
  
  
  

  
  
  • • If the patient is in cardiac arrest, the quality and effectiveness of chest compressions are assessed. The quality of chest compressions is determined by the quantitative waveform capnography; however, if that is not available, the depth and rate of compressions are monitored by another HCP. Cardiac rhythm is assessed by monitoring the ECG or getting a 12-lead ECG.
    
  • • Whether an intravenous/osseous access has been established.
    
  • • If return of spontaneous circulation has been achieved, check for haemodynamic stability (check blood pressure, pulse rate, cardiac rhythm, relevant lab investigations such as blood glucose, electrolytes, etc.)
    
  • • The requirement of medications and fluids to maintain blood pressure.
  
  
• • Management:
  
  
  

  
  
  1. i. If CPR is being given and end-tidal CO₂ is below 10 mm of Hg, then the quality of compressions needs to be improved. Effective compression means end-tidal CO₂ should be > 10 mmHg.
     
  2. ii. Based on the ECG and haemodynamic findings, appropriate electrical and/or pharmacological therapy should be initiated as per the appropriate algorithms of international guidelines.
     
  3. iii. Pulse and blood pressure are to be monitored, and fluid and drugs are to be given accordingly. If hypotension is because of anaphylaxis, immediately raise both feet by 60 degrees and rapidly infuse 1–2 L of Ringer’s lactate or isotonic saline.
     
  4. iv. If a definitive airway has been inserted during CPR, then compressions are given at the rate of 100–120 per minute without interruption and breaths are given once every 6 s, which is 10 breaths/min, instead of cycles of compression and ventilation in 30:2 ratio (see BLS assessment and management in the following).

Disability:

• • Assessment: Check for neurological functions and any changes therein. This is done by assessing the level of consciousness, using the mnemonic AVPU (Alert, responds to Voice, Pain or Unresponsive). This will tell us about the features of stroke and status of pupils.
  
• • Management: Any deterioration in neurological functions is managed on a case-to-case basis. In case the patient becomes unresponsive at any time, the BLS assessment and management is instituted (Fig. 1.17.1).

Exposure:

• • Assessment: The patient is exposed to look for anything that could have been missed earlier, e.g. trauma, bleeding, burns, urticarial, wheal, unusual markings or medical alert bracelets. Once the assessment has been completed, the patient must be covered properly.
  
• • Management: The additional information may lead to additional differential diagnoses, thereby modifying the management plan(s) (Table 1.17.1).

TABLE 1.17.1

Summary of Primary Assessment and Management

Component	Assessment of	Management
Airway	Patency of the airway	Open the airway using manoeuvres and/or adjuncts, or medication
Breathing	Adequacy of ventilation and oxygenation	Provide supplementary oxygen and support ventilation, as needed
Circulation	Quality of compressions (if in arrest). Haemodynamic status if circulation present (heart rate and rhythm; BP; peripheral perfusion, etc.)	Provide high-quality compressions, if in arrest Stabilize unstable condition by appropriate measures
Disability	Neurological functions	Manage deteriorating neurological status as required. If becomes unresponsive, add BLS assessment and management
Exposure	Anything missed. Cover after assessment	Manage as required

Adapted from M.W. Donnino, K. Navarro, K. Berg, S.C. Brooks, J. Crider, et al and AHA ACLS Project Team. Advanced Cardiovascular Life Support (ACLS) Provider Manual, American Heart Association, 2016, Dallas, Texas.

Secondary assessment and management

The secondary assessment and management goes hand-in-hand with the primary assessment and management with the aim to facilitate diagnosing the cause(s) of the patient’s condition (or change in condition) and to help in fine-tuning its management. Secondary assessment has two components: structured history taking in an organized way and sifting through the usual and most frequently encountered cause(s) for sudden adverse condition in patients.

Structured history taking:

• • Assessment: The structured history is elicited by the simple to remember mnemonic SAMPLE which stands for: Signs and Symptoms, Allergies, Medications (including the last dose), Past medical history (especially related to current illness), Last meal and Events that have led to the present condition. This history can be taken from the patient himself or his attendants.
  
• • Management: Modify the management going on during primary and secondary assessment and management as per the new information and findings.

Sifting through the most frequently encountered cause(s):

• • Assessment: The recommended method to explore the most common causes is to revisit the five H’s and 5 T’s; the H’s being hypovolemia, hypoxia, hydrogen ion (acidosis), hyper-/hypokalemia and hypothermia, and the T’s being tamponade-pulmonary (tension pneumothorax), tamponade (cardiac), thrombosis (pulmonary), thrombosis (coronary) and toxins. The HCPs also order relevant investigations to supplement the findings of SAMPLE history and H’s and T’s so as to arrive at the diagnoses for the adverse condition of the patient and plan the management accordingly.
  
• • Management: Modify the management going on during primary and secondary assessment and management or BLS assessment and management as per the new information and findings (Table 1.17.2).

TABLE 1.17.2

Summary of the Steps of Secondary Assessment and Management. The Aim is To Facilitate Diagnosing The Cause(S) of Patient’s Condition (Or Change in Condition) and Help in Fine-Tuning the Management

COMPONENT CONSISTS OF
SAMPLE history	• Signs and Symptoms • Allergies • Medications • Past medical History • Last meal and • Events leading to the present condition
H’s and T’s	• H’s • hypovolemia • hypoxia • hydrogen ion (acidosis) • hyper-/hypokalemia • hypothermia	• T’s • tamponade-pulmonary • tamponade (cardiac) • thrombosis (pulmonary) • thrombosis (coronary) • toxins

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